It is my pleasure now to introduce Sorel Myberg to address the evaluation of the patient with GERD. Sorel is a nurse practitioner specialist in Rochester, Minnesota. He graduated with honors in 2015 and has over seven years of diverse experience as a nurse practitioner. He affiliates with many hospitals, including Mayo Clinic Hospital in Rochester and Mayo Clinic Health System, and he collaborates with many doctors and specialists in the Mayo Clinic group. Sorel, I turn it over to you. Thank you for the introduction, Sarah. Today I'll be talking to you about how to evaluate a patient with gastrointestinal reflux disease, or commonly known as GERD. I have no financial disclosures. We'll be covering what GERD is, why does it occur, what are the complications we see, especially in untreated GERD, the testing options we have to make a diagnosis of GERD, and finally how to treat GERD. First, what is GERD? Typical symptoms are heartburn and regurgitation. Heartburn is the most common symptom of GERD, and it's described as substernal burning that starts in the epigastric area, moving up to the neck. Then regurgitation as movement of gastric contents into the mouth can be acidic in nature. I would say the takeaway point from this slide is to really focus in on the history and ask specific questions. Symptoms of GERD can be nonspecific and can overlap with conditions like rumination syndrome, akalasia, eosinophagitis, cardiac and pulmonary condition, as well as hypersensitivity conditions. Regurgitation is usually postprandial or when patients are bending over or if they are in the recumbent position. Extraesophageal symptoms or atypical symptoms are commonly seen in the esophagus clinic, and they are divided between pulmonary and laryngeal symptoms. These symptoms are frustrating for patients and providers alike and can be difficult to treat at times. It's oftentimes a multifactorial influence here causing the symptoms. Approximately about 10 to 20 percent of the population in the western has weekly heartburn or acid reflux. We see clinically troublesome heartburn in about six percent of the population. Patients with GERD have lower quality of life as evidenced by decreased work production and lower scores on sleep scales. Now GERDs can be equal in gender. We see more esophagitis in males, those over 40, and those who smoke. The Los Angeles classification system is used to classify esophagitis. As you can see there, grade A and B can be objective while grade C and D is more severe esophagitis. Next, why does GERD occur? The pathogenesis of GERD is multifactorial. Some degree of GERD can be normal, but it reaches pathologic levels if there's a failure in the protective mechanisms. This can be anything from decreased salivation that fails to buffer the acid to decreased esophageal motility in patients with esophageal motility disorders all the way to gastroparesis. Common question that you will have in your practice is really to think about when to do endoscopy when you see patients with GERD. I would say if you see a patient with a typical GERD symptoms and they have no alarm symptoms, it's reasonable to start them on an empiric PPI trial. More about this later. On the other hand, endoscopy is indicated when you have a patient with alarm symptoms, especially if they're over 50, and long-standing symptoms. Alarm symptoms include bleeding, dysphagia, non-cardiac chest pain, epigastric mass, weight loss, and refractory symptoms despite medical therapy. An important take-home point on reflux esophagitis is it's important to start these patients on twice-daily PPI and give them at least two months for the reflux to heal, and then repeat endoscopy to make sure they don't have BERITs. Recommendations of a grade C and D esophagitis in my practice, I include B, C, and D. Cyril, can I ask you a question? Go ahead. So, why is it not a good idea to biopsy for BERITs, you know, in this setting of active esophagitis? What happens or do you miss something? Yeah, you can certainly, you know, miss it. There's a lot of information you don't get given a good idea of what the BERIT segment looks like. Nice. Thank you. So, what are the complications for GERD? We see peptic strictures, Schatzky's ring, bleeding, or iron deficiency anemia, BERIT esophagus, and even esophageal adenocarcinoma. In 2017, the Lyon consensus was established to help providers with criteria to how to diagnose GERD as well as give indications how to test for GERD. You can diagnose GERD if you see grade C or D esophagitis on endoscopy, if there's evidence of long segment BERITs, and if patients have a distal esophageal acid exposure time of 6% or greater on pH monitoring. On the other end, indications for testing is for those patients with atypical symptoms, usually on PPI therapy, if symptoms are unresponsive to anti-secretory therapy, and important to do pH testing before reflux surgery. Testing options for GERD, first is a Bravo pH monitoring system. This is a small device that's attached to the distal esophagus, usually about 6 cm proximal to the G-junction. It transmits to the Bravo pack, as you see in the left lower corner. Patients usually have to have it either on their waist or around their neck. This is usually well-tolerated, patients can shower, it doesn't really interfere with their daily activities. A small percent of patients will have significant chest pain with this, and I've had to take two of these Bravo capsules out because of that, but that's not very common. Cyril, can you still use a probe type of pH metery device? Does that even exist anymore? Yep, and I will talk about that next. Time frame for Bravo, it's usually 48 hours, but you can go up to 96 hours. Next, John, is the ambulatory pH and impedance monitor. As you can see here, it's a catheter that is through the nose and usually taped to the cheek. It has pH sensors in the esophagus, as well as a pH sensor in the stomach. It also has impedance sensors that pick up non-acid reflux. This can be uncomfortable, it alters patients' diet and their activity, and there are some sensitivity issues, as one study showed that up to 26% of patients have erosive esophagitis with a normal pH impedance. Comparing the Bravo and the impedance, Bravo is 48 hours usually, it can be up to 96 hours. You cannot measure gastric pH, you cannot measure non-acid reflux. Ideal patients, intermittent typical patients, are typical symptoms off of PPI. On the other hand, the pH impedance, usually done for 24 hours, it is able to measure gastric acid or pH, and it can give you a sense of non-acid reflux. Typical or ideal patient, there's frequent atypical symptoms on PPI. I usually ask myself these two questions, does the patient have reflux? If you want that answer, the best test, I think, is a 48-hour Bravo. You have them stop their PPI 7 to 10 days, and H2 blockers about three days before the Bravo test. If they have significant reflux or burning symptoms, you can have them use anti-acids up until the day before the Bravo. The other question is, are the patients continued symptoms as a result of acid or non-acid reflux disease, and the patient that you have on high-dose PPI and even H2 blockers? Best to do a 24-hour pH impedance testing on therapy. Manometry is required prior to placing a pH impedance test. Prior to placing a pH impedance test, so you can get an exact location of the lower esophageal sphincter. Next, how do we manage GERD? First of all, lifestyle modifications. In my practice, I really push the weight loss if patients are overweight. Hit a bed elevation. I ask four to six inches if they can tolerate that, and avoiding meals up to three hours before bedtime. In regards to diet, I generally don't have them avoid a global diet of acidic food or spicy food. I ask my patients to avoid trigger foods if they have them. This meta-analysis was done on an empiric trial of acid suppression. It was found to be simple. This can only be given if patients have no alarm symptoms. You get a quick symptom response in about two weeks, and it's cost-effective. Moving on to PPI. It's the mainstay of management of gastroesophageal reflux symptoms. It's usually given 30 to 60 minutes before meals. You can see that the healing esophagitis of PPI and the symptom resolution is superior when compared to H2 blockers. For patients with non-erosive disease, you can certainly use on-demand therapy. For example, give them PPI for two weeks and stop or titrate it down to see how they do. On the other hand, if patients have erosive esophagitis, they usually need indefinite therapy as they will have recurrence of esophagitis off of PPI. So Sorel, before you leave this slide, can I ask you a couple of questions? So with the PPI, the need to take it a half an hour or an hour before meals, what's the point of the before meals part? I've heard patients say that's inconvenient. You know, if they can't do it, then can they, you know, take it at some other time? Why do we instruct them that way? And is it okay to take it a different way? Yeah, that's a really good question, John. That's a question I oftentimes get in the practice. The PPI are really taken on an empty stomach and given at least half an hour to absorb into the bloodstream. And then I really ask my patients to do eat something. They need to chew and swallow a solid food. And then these acid pumps are turned on and the medication is right there to block it. If you take it, if they forget, I still ask them to take it, but they lose about 50% of their PPI dose. That's a lot. That's quite a bit. I didn't know it was that high. Side effects of PPI, common that we see diarrhea, headache, abdominal pain. There does not tend to be a difference if you switch them between a different PPI and the side effects. I sometimes will try patients on a low dose PPI on a Monday, Wednesday, Friday type of schedule to see if they have any improvement in their side effects. The other option is to use H2 blockers. What's the abdominal pain related to PPIs feel like? What sort of abdominal discomfort is that? They usually get kind of an epigastric type of burning symptoms, more of a dyspepsia symptoms. This is quite a controversial issue in the world of PPIs, and you will likely have a lot of questions regarding this. I'm not going to go in too much detail. I will talk about the plavix and bone fractures. That's something that I come across in my practice quite a bit. I'm going to come on the slides. The bottom line is these studies, in my mind, does not prove cause and effect. Hip factor is a question I'm asked a lot in practice. I usually have patients take a calcium and vitamin D supplement. There are no societal guidelines to follow patients with bone density scan testing or to decrease patients that have diagnosed osteoporosis to decrease the dose, their PPI dose. So, Cyril, these are issues that really get a lot of play in the lay press. I'm sure you have, in your busy practice, patients coming to you saying, hey, I'm worried about osteoporosis. I'm the demographic that's most at risk for this. My heartburn is really severe. These medications, these PPIs help me, but I really need to stop this drug because I'm worried about bone fractures. What do you do for people? Yeah, that's a question that comes up quite a lot. I would say you just sit down and have a good discussion with them about the options you have. And I will talk more a little bit about a later slide. It's really what do we have to treat their GERD symptoms. Another common question that comes up in practice is what do you do with people, patients that are on a PPI and on Plavix, as it tends to be metabolized by the same enzyme? Strongest evidence is omeprazole. There's really inconsistent effects on cardiovascular outcomes, and the FDA discourages contaminant use. Here we separate PPI and Plavix by 12 hours, have them take their PPI in the morning and Plavix in the evening. If they're on twice a day PPI, we sometimes have them take their PPI before their lunch meal and the Plavix at bedtime. Or switch them to Protonix altogether as it doesn't come with that interaction. There's really no evidence that PPI should be discontinued if patients are on Plavix for coronary artery disease. A little bit about the management of atypical symptoms. It's important to get objective evidence of GERD, as some patients can have concurrent GERD and atypical symptoms. Patients with atypical symptoms really have a poor response to anti-reflux surgery. That's discouraged. And just refer patients to the necessary pulmonary ENT or allergy, all depends on what's their main symptom. Surgery is the last resort. Several options. I won't go into too much detail of what there are. There are endoscopic options, the TIF, T-I-F. There's a magnetic LYNX device. Then there's a gold standard Nissan front application, either with a 360-degree wrap or a partial wraps. Important to focus on the best results part of the top right of the slide. Surgery really works best if patients have typical symptoms. You've given them a PPI trial and they really had a good response, and they have abnormal pH testing. You can consider surgery in patients with significant erosive disease despite high-dose PPI and in patients with large hiatal hernia that get aspiration pneumonia. Another common question that comes, what do you do with patients with a high BMI and the setting of reflux and hiatal hernia? We tend to send them to the bariatric surgery clinic for evaluation. Most people after a Nissan front application are really symptom-free at one year. About 60% require medical therapy in 10 years. Side effects common to see dysphagia early can be related to a tight wrap and even some dysphagia late. Patients have the inability to vomit and a lot of symptoms with gas bloat syndrome that I see in my clinic after a Nissan front application. It really comes down to just sitting down with your patient, having a discussion and weighing out the option for treatment of their GERD. If you give them H2 blocker therapy, they could have uncontrolled symptoms. There's a risk for complication. Compare that to potential side effects of the front application and PPI. What should we do long-term on patients with PPI? I really try to use the lowest dose of acid suppression that's required to treat their symptoms. Stop the PPI when it's not needed and consider H2 blocker therapy. There's no societal guidelines or recommendation for laboratory testing. In my practice, I have patients check their creatinine every year, B12 and magnesium every three years, and a CBC every two years. Clinical pearls for GERD endoscopy is indicated for red flag symptoms. PPI is really the mainstay therapy for GERD. H2 blockers can be used for breakthrough symptoms at night. Be sure that patients are on the lowest dose of PPI. Repeat the endoscopy in eight weeks in patients with grade C and D esophagitis. In my practice, I include B. Front application works best in typical GERD symptoms. Surgery is really the last option if everything else fails, including lifestyle and medical therapy. Be careful to combine PPI with antibiotics to prevent C. diff, and caution for patients traveling internationally, especially to a third world country, if they are on high dose PPI to prevent gastroenteritis. And really weighing out the options for treatment in GERD with your patients. Moving on to some polling questions. The first question is, you have a 42-year-old male referred for GERD. He has heartburn symptoms about two to three times a week after meals, regurgitation about once a month. He's used formaldehyde 20 milligrams once daily with partial improvement in his heartburn symptoms. He has gained 20 pounds. He has no alarm symptoms. His exam is normal. What is the most appropriate next step? Increase the formaldehyde to 20 milligrams once daily. Initiate patient on a period PPI trial, perform endoscopy, or perform barium esophagram. I agree. That looks good. So that's just the empiric PPI trial. And patients with no alarm symptoms, it's reasonable to start them on a PPI. And two 55-year-old overweight Caucasian male with 20-year history of GERD. He describes breakthrough heartburn symptoms twice a week over the last six months. He has a medinophagia of a solid foods. Upper endoscopy shows great CSF vagitis. His weight is stable. He's taken omeprazole 20 milligrams once daily. He continues to smoke and his exam is normal. What is the most appropriate next step? Increase omeprazole to 40 milligrams twice daily. And no need to repeat endoscopy if his symptoms are under control. Increase omeprazole to 40 milligrams twice daily and repeat endoscopy in eight weeks. Perform a pH impedance testing and perform barium esophagram. Yeah, that's the right answer I was looking for. It's increasing omeprazole to twice daily and repeat endoscopy in eight weeks to really make sure that reflux damage is healed and to rule out Barrett's. Usually decrease the dose to a once-daily dose after that. Last question is a 51-year-old female that's referred for Horshansen cough. Her local ear, nose, and throat doctor told that she has GERD based on their endoscopy. She denies, you know, typical GERD symptoms. She's not on any PPIs. What is the most appropriate next step? Refer to ENT for repeat laryngoscopy. Start patient on a PPI trial and refer for endoscopy. Refer patient for anti-reflux surgery if she does not respond to PPI. Refer patient for endoscopy with Bravo pH monitoring. If we look at the guideline, the answer I was looking for is to really get objective evidence. She has no typical symptoms of GERD. So G would be to get Bravo testing done to get evidence of GERD. Can I ask you a quick question there? Go ahead. Is part of the reason for that because you don't want the PPIs to be started and then do pH monitoring and have an inaccurate pH metric result? Correct. Don't, you know, commit patients to long-term PPI if they don't have typical symptoms. Got it. We apologize. Overhead speaker there. We're going to switch to our webcam mic because Sorelle and I want to have a little bit of a conversation with you here because GERD is really such a clinical burden, isn't it? There are so many people that have GERD. It is. It's really very common. And, you know, that's what I see a lot of every day. And just that history is important. Really having that discussion, what's really the best treatment options for them. It's also important. What percentage of your practice would you say is, what percentage of your practice is GERD patients of one form or another, whether it's typical or atypical GERD? It's probably over half of the practice that I see is those GERD patients. And yours is a referral practice, right? So many of these people have been seen by other gastroenterologists first. So even in a referral esophageal practice, the burden is over 50%. Correct. That's really amazing. Can I ask you a couple of questions about GERD-related procedures that you were describing? So you were talking about a Nissen fundoplication. Can you describe briefly what that surgery is or what it looks like? So the Nissen fundoplication is usually done laparoscopically with four or five incisions in the abdomen. Then we'll reduce the hiatal hernia and perform a 360-degree wrap to prevent recurrence and reflux. I often have the discussion about the patient about, you commonly see gastro-syndrome symptoms. There are some patients with dysphagia. It's all things to think about, but I think overall, it's a good procedure if everything else fails. Now, I think you were alluding to the need to perform an esophageal manometry before considering a Nissen or any other wrap or fundoplication. Fundoplication and wrap mean the same thing, right? But what's the importance of that manometry pre-op? The importance is to make sure these patients don't have a esophageal motility issue because if you're going to perform a fundoplication or wrap and their esophagus doesn't squeeze well, they will have significant dysphagia. I see. I'm less familiar with LYNX. I'm familiar to some extent with TIFF. I'd love it if you could explain those two procedures to me and also whether we need to perform esophageal manometry before those. Manometry is recommended before both those procedures. The LYNX device is a magnetic device that's placed below the G-junction to help tighten that area up. It's fallen a little bit out of favor here at Mayo Clinic. There are some issues with the size of the hiatal hernia. Patients can't really have a big hiatal hernia. There was some initial concern with the LYNX device migrating into the tissue, actually, so we don't place them here. The other newer procedure is a TIFF that's endoscopic done. It's a wrap that can be done either 270 degrees, mostly done for regurgitation symptoms, especially folks that have a lot of regurgitation at night. Also a good option if a patient doesn't want to have the full wrap and the laparoscopic incisions. I see. Just to clarify, then, the LYNX, which looks like a necklace, right, around sort of the top of the stomach by the cardia, that's a laparoscopic procedure, correct? Yes. So that's surgery, but the TIFF is done with an endoscope. Endoscope. Got it. Thank you. So you don't tend to refer for LYNX. Do you refer for TIFF procedures, and who do you choose to refer for an endoscopic wrap as opposed to, say, a surgical wrap like a Nissen? Yeah, that's a good question, and really based on what the patient's symptoms are and what they prefer to have done. Most of the TIFFs come referred to us as patients that really have done a lot of research on the TIFF and are really interested in the endoscopic approach. They don't want the abdominal incisions. So would you say that in your practice, you refer for Nissens more frequently than you would for the other two procedures? Correct. I see. Do you have any insight into the durability of a Nissen? So like if I'm a patient and I come to you and you feel that it's reasonable for me to undergo a laparoscopic Nissen fundoplication for my GERD, can I assume that that will keep me off of PPIs for the rest of my life, or is there any concern about durability of a fundoplication? Yeah, there is a concern. Like I said earlier, most patients are symptom-free within that next year, but if you get to about the 10-year mark, about 60% of patients are back on PPI. It also depends on what their BMI is. I know the surgeons here prefer the BMI to about 30, so there's some variables there. Got it. And I take it if it's not durable, then what do you do? You restart medication? We restart medication as the risk of a second surgery or failure is higher than the first I see. I see. That's really good to know. Are there still issues when you're having to sort of go up on the dose or the frequency of PPIs in terms of third-party payer coverage? Is that still an issue? That's an everyday issue. Usually I find that omeprazole and pentoprazole is covered the best. It all depends on the patient's insurance and their symptoms. I tend to go to Nexium or esomeprazole next if omeprazole is not working. And dexelen is the next option after that, but it's usually not covered by insurance. I see. There are actually some attendee questions that I'm seeing come up that are interesting, and we really appreciate the audience and attendees sending us questions. Here's one that says, if a patient is known to have GERD and is planning to get anti-reflux surgery, why do you need to do pH testing prior to surgery? Yeah, we really need to prove that this is what they have before committing them to a surgery or a new kind of application. And how about this? You mentioned that manometry should be completed before pH impedance. We don't do that in my practice. Is that possibly skewing our results? Yeah, so the manometry is helpful to tell you exactly where the G-junction is. Otherwise, you just drop in the pH catheter until it hits the stomach acid. So in our practice, I would prefer to give us an exact idea where the G-junction is so you can place the pH catheter accordingly. I see. So there's, as you were mentioning, pH metery, which is measuring pH to look for acid reflux. But there's also pH impedance, which I guess is one catheter, correct? Correct. Does that. But that's not a capsule that's clipped to the esophagus. That actually has to go through the nose. Through the nose. And then it measures the acid reflux as well as the non-acid reflux. So that's not, presumably, a 24-hour or a 48-hour measurement, right? That is a 24-hour measurement. It is. So is the only downside to doing pH impedance on everybody and ditching pH, Bravo pH alone, is the only reason not to do that because it requires the discomfort of going through the nose to do pH impedance, or is it an expense issue? Why do you do, why do you bother with the acid test only if an acid and alkaline combined test is available? Sure. It really depends on what the question is you want to answer. If patients have typical or atypical symptoms, do you want to rule out GERD as a cause of cough, for example? So that's, it all depends on the situation. I see. And this is a great question. How does pH impedance on therapy, and I think that means acid suppression, help to evaluate for GERD if the PPI is altering the pH? So mostly you will do that procedure on medicine. If you see a patient in the clinic that have some symptoms that you have, for example, on twice a day on maprazole, and they still have some heartburn symptoms and you want to know, are those symptoms related to reflux or not? Or is it mostly a patient with non-acid reflux that has esophageal hypersensitivity? I see. Well, that's really great, Sorel. This is reducing my confusion with how to work up GERD and how to treat it and so forth.

GERD

evaluation

management

symptoms

diagnosis

PPIs

surgical options